Tag Archives: Drug Distribution

Throughout the rotation, I had the opportunity to be involved with handling orders for non-formulary medications. (For excluded medications, the majority of them are able to be auto-subbed as per the policy: automatic-therapeutic-interchange-adult-patients).

Non-formulary medications are medications where no decision has been made on whether it should be on the formulary, or are restricted drugs that have not met the restriction criteria. For non-formulary and excluded drugs to be started/continued in the hospital, they need to meet the following criteria based on the policy:

Efficacy and safety is supported by evidence

Drug is clinically appropriate for patient

No acceptable formulary alternatives

For excluded drugs, use should be limited to exceptional circumstances around patient-specific factors only

If patients were on a non-formulary medication PTA and the above criteria are met, pharmacy will try to coordinate so that patient can use patient’s own medications (POM). For POMs that are scheduled daily and not OTCs, they will be flagged and pharmacy technicians will follow up and check if patients have their own supply. If they have their own supply, it will be brought back to the pharmacy for identification and verification.

If patients cannot supply or supply is not considered usable (e.g. a low hazardous drug, blister packed medications) and cannot be held during hospital stay, the pharmacist will fill out a “Non-Formulary and Excluded Drug Approval Form”. If cost per day < $100, the dispensary supervisor can approve it and if >$100, the clinical coordinator can approve it. Ordering the supply of non-formulary drugs is the same process for formulary drugs.

Microbiologist recommended cefotaxime IV for coverage and the pediatrician wanted to use the meningitis dose

Order was written for cefotaxime 375mg IV Q6H

For all neonatal + pediatric medications, pharmacists have to check the dose

As per C&W online formulary and progress notes, the dose is appropriate

In order to select the correct set (LK-), it is important to refer to the pediatric PDTM (45 wks post-menstrual [gestational age + chronological age] to 17yo). The Alaris Pump has a drug library based on the PDTM, with different profiles such as Adult, Critical Care, Maternity, etc.

Dose is < 920mg – therefore, it would be in a syringe
→ selected kit: Peds Cefotaxime IV 40mg/mL (up to 920mg)

For the Alaris pump, there needs to be a minimum of 2mL extra to prime the line. When the syringe is programmed for the dose, it will prime the line and then only dispense the volume of drug ordered (any remaining volume in the syringe will be discarded).

After the order is verified, it proceeds to the filling station where 4 labels are printed out (for 4 syringes) and goes to be made.

For pediatric orders, there are “recipe” sets that the IV tech has to follow when mixing:

For this order, the cefotaxime 1g vial (200mg/mL) has to be diluted to 40mg/mL and the recipe provides steps on how to do that

The following policy has to be followed for compounding sterile preparations: compounded-sterile-preps-aseptic-technique. Prior to going in the IV room, the IV tech alcohol wipes all the supplies (syringes, vials, etc.) and places it in an alcohol-wiped bin. This bin is placed in a designated sterile area near the window into the IV mixing room.

I was able to follow the IV tech into the mixing room, and had to follow the garbing procedure as FH policy: garbing-poster. After wearing all the protective equipment, we step over to the “clean” area where the laminar hood and extra mixing supplies are kept and are not able to step back into the ante room unless we are planning to de-garb. The laminar hood needs to be alcohol-wiped prior to mixing. As well, all the hard or plastic supplies placed into the laminar hood have to be alcohol-wiped and mixing occurs 6 inches into the laminar hood where it is considered sterile. It is important to avoid blocking the air flow (flowing from the back of the hood towards the mixer) from the product to ensure sterility, as well as, to avoid contacting critical sites (like the syringe plunger). 2 really cool things in the LMH IV room was that there was a “product/vial-shaking” machine and an intercom for techs to use if they needed supplies from outside! 😮 Some things to keep in mind when mixing are that the expiry date on vials are actually “best used” dates – so even if a drug was expiring today, as long as it was reconstituted and injected into the bag, the stability of the full product is extended to the stated expiry of the stability chart – an example: civa-recon-and-stability-chart-adult-aug-2014, as well as, that all syringes are only good for 24 hours after mixing. So for this order, we mixed 4 luer-locked syringes which will help cover the next 24 hours. The preparations are wiped and passed back to the IV prep room through the window to be checked. After exiting the IV room, IV tech wear a white coat to protect their environment from their contaminated scrubs.

During my rotation, I had the opportunity to be involved in the different steps of drug distribution. At Langley Memorial Hospital, orders are prepared via a pharm tech order entry and pharmacist verification system (pharmacists are also able to do both order entry and verify). Drugs are distributed as automated unit doses (AUD) and if it is not a bulk item, wardstock or excluded drug, scheduled drugs are packaged by the Langley Pharmacy Drug Distribution Centre (PDDC). Fill lists run at 6:30pm daily (Pharmacy closes at 6pm) and the rolls are ready by 4:30am. Rolls arrive in the morning (with the patient’s name header on the top, followed by the patient’s scheduled meds) and pharmacy technicians sort the rolls and deliver them to the ward by 800hr. When delivering, they also collect the previous day bins and any pharmacy returns (incl. fridge items) which are sorted for recycling in the morning. For orders that are faxed throughout the day – pharmacy has to prepare and deliver an interim supply of scheduled and PRN meds until the rolls can come in from PDDC the next morning. If later during the hospital stay, the patient requires more PRN meds – the ward will send down a prescription refill request form (has patient’s name and medication) and pharmacy will check Rx Audit (to see previous debits/refills and assess quantity to send) and debit the quantity, print a label and send the supply to the ward.

When verifying new orders, pharmacists highlight the orders that require an interim supply and the order goes to the filling station where it has to either be filled and checked by 2 separate pharmacy technicians or 1 pharmacist (who would have to initial on the order and on the label). One difference between checking in community and hospital is that the label does not contain the DIN and brands are generally interchangeable, so there is no double check with the DIN. If they are not stat orders, the interim supplies are placed into their ward-specific bin to be delivered throughout the day. If it is a stat, the supply is delivered as soon as possible by the pharmacy technician and is either placed into the pharmacy bin, given directly to the clinical pharmacist or given directly to the nurse taking care of the patient. If it is a fridge item, it will be placed in the fridge in the room-specific bin. For extended care, drivers come by to pick up the interim supplies and patient profiles documenting the changes at certain times of the day.

At his current renal function (stable), metformin is safe (nurse practitioner unaware of any tolerability issues with metformin).

Metformin has a very low risk for hypoglycemia, and as a result, is considered quite safe in the elderly

Action:

Called ward to let them know to hold the morning dose until I was able to speak to the prescriber

I had spoken to the unit clerk instead of the nurse taking care of the patient – in the future, will ask to speak to the nurse and inquire when the nurse practitioner (prescriber) is on the ward

Discussed with nurse practitioner on above issues – NP to reassess, and plans to continue metformin and discontinue gliclazide (patient to be discharged tomorrow). Nurse to fax new order. Aware that last HbA1c was ~6 months ago.

Document on order that order for stop metformin and decrease gliclazide was not entered and copied to clinical as an FYI that issue has been discussed with NP and NP to R/A

FYI Metformin in renal dysfunction:

Lexicomp:

eGFR 30-45: initiation is not recommended. may consider dose reduction by 50% (e.g. of current dose or max dose) and monitor renal function q 3 mos

eGFR <30: use is contraindicated

CCS HF Compendium guidelines: Metformin may be considered a first-line agent for diabetes treatment if the eGFR is greater than 30 mL/min. However, care should be taken to temporarily discontinue metformin if renal function worsens significantly.